Purpose : We evaluated the results of surgical treatments for cervical spondylotic myelopathy in elderly patients (75-90 years old) and pre-elderly patients (65-75 years old).
Materials and Methods : We examined the Japanese Orthopaedic Association (JOA) score preoperatively, immediately after surgery, and 6 months after surgery, as well as the recovery rate (R.R.) in elderly patients (41 cases) and pre-elderly patients (64 cases). Operative procedures included anterior cervical disectomy and fusion (ACDF) (20 cases), posterior decompression (PD) (46 cases) (laminectomy : 6 cases, open-door laminoplasty : 19 cases, and French-door laminoplasty : 21 cases), and posterior decompression and posterior lateral fixation (39 cases).
Results : In the elderly patient group, the R.R. in the immediate postoperative period was 67.6%, the R.R. at 6 months after the operation was 60.9%, and the latest R.R. was 73.8%. In the pre-elderly patient group, the R.R. in the immediate postoperative period was 67.2%, the R.R. at 6 months after the operation was 71.9%, and the latest R.R. was 85.0%. In both groups, the R.R. was high. There was no significant difference between the R.R. in both groups in the immediate postoperative period. The R.R. in the pre-elderly patient group increased 6 months later but the R.R. in the elderly patient group decreased at that point. However, at the recent follow-up, the R.R. increased again in both groups. Postoperative complications were transient delirium in 11 cases (10.4%), pneumonia in 2 cases (1.9%), C5 palsy in 2 cases (1.9%), dysphagia in 2 cases (1.9%), displacement of ceramic spacer in 2 cases (1.9%), and postoperative infection in 1 case (0.9%).
Discussion : Both the elderly and pre-elderly patient groups had good surgical outcomes despite operative procedures. We should perform surgery in patients complaining of neurological symptoms as early as possible while taking care of the general medical condition, and the familial and social backgrounds. We should operate as less invasively as possible and let the patients attempt walking as early as possible to avoid post-operative complications.
Objective : To assess the perioperative fractional anisotropy (FA) /apparent diffusion coefficient (ADC) change in patients with cerebrospinal disease using highly accurate diffusion tensor imaging (Zoom DTI), and to determine the prognostic value.
Methods : Fifty patients with cervical spondylotic myelopathy (CSM) and 12 healthy controls were enrolled. Of these, 36 patients (72%) had intracordal high intensity in MRI T2WI before surgery. All patients underwent decompressive surgery. Zoom DTI and the Japanese Orthopedic Association (JOA) assessment were performed before surgery and one week and six months after surgery. The axial plane of the most stenotic cervical level was assessed. Intracranial hemorrhage (ICH) and chronic subdural hemorrhage (CSDH) were also estimated.
Results : The FA at one week after surgery significantly decreased compared to the FA before the surgery in CSM patients ; the preoperative FA value in CSM patients did not differ from normal controls. The FA values of patients with intracordal high intensity in MRI T2WI significantly decreased after surgery and had an increasing trend from one week to six months postoperatively, while those of patients without intracordal high intensity in MRI T2WI did not change significantly during the perioperative period. The FA values at one week after surgery had a significant positive relationship with the JOA scores before surgery and at six months after the surgery. The ADC values before the surgery showed a negative relationship with the JOA scores at six months postoperatively ; however, it did not differ during the perioperative period. The FA value of ICH patients significantly decreased, and the FA value of CSDH patients significantly increased slightly. The FA value of the compressed normal muscle fiber resulted in a significantly increased value, which implied that the FA value of the fiber increased in the compressed situation.
Conclusions : It was not the FA value before the surgery, but the FA value at one week after surgery that showed a positive relationship with the JOA score at six months after surgery. We concluded that the postoperative FA value approximates the true state of the damaged cord, and that it could be a more accurate prognostic factor. The preoperative FA value includes a masking effect, as an “aligned fibers effect,” due to the compression by degenerative construction, which was confirmed by further studying the compressed normal muscle fiber DTI.
Introduction : Osteoporotic vertebral fractures are known to increase periods of inactivity due to pain. Prolonged bed rest diminishes the capacity to perform activities of daily living (ADL), and contributes to the development of further medical complications in older adults. If the ADL capacity does not recover, it is often difficult for patients to return to their previous level or even return to their former residence. Accordingly, vertebroplasty has been performed regularly, since the 1990s, to provide pain relief for osteoporotic vertebral fracture patients. Various reports have claimed that vertebroplasty achieves acceptable pain control and satisfactory recovery of the patients' quality of life and ADL capacity. However, we have encountered cases with poor recovery of the ADL capacity, despite achieving a pain-free status. We aimed to evaluate the factors associated with poor recovery of the capacity to perform ADL after vertebroplasty.
Methods : There were 483 consecutive patients with osteoporotic vertebral fractures who were admitted to our hospital between April 2016 and March 2019. Among these, 34 underwent percutaneous vertebroplasty with hydroxyapatite. The following parameters were compared between the patients who showed a good recovery of their ADL capacity and those who showed a poor recovery : age, presence of prevalent fracture, past medical history (stroke, diabetes mellitus, renal dysfunction, Parkinson's disease, and psychiatric disorders), medications (steroids, anti-dementia drugs, and psychotropic drugs), body mass index, period from the onset of symptoms to the surgery (less than two weeks or over two weeks), preoperative and postoperative verbal rating scale pain scores, and uncomplicated rehabilitation.
Results : The mean age of the 34 patients (male, n=9 ; female, n=25) was 80 years. Past medical history and medication use could not be statistically analyzed because of the small number of cases. There were no significant differences observed in the following parameters: presence of prevalent fracture, body mass index, period from onset to operation, and preoperative and postoperative verbal rating scales. Age>80 years (p=0.03) and complicated rehabilitation (p=0.002) were associated with a significantly poorer recovery of the capacity to perform ADL.
The causes of “dropped head syndrome” are roughly classified into neurogenic and myogenic factors. Diseases due to neurogenic factors include amyotrophic lateral sclerosis, Parkinson's disease, and spondylosis. Isolated neck extensor myopathy (INEM), a myogenic disease noted here, was named by Katz, which is based on idiopathic and localized posterior neck extensor muscle atrophy. The clinical features of INEM reveal that onset in the elderly, and cervical spinal kyphosis and myelopathy develop over one year after the dropped head phenomenon. We present the case of a 69-year-old woman with dropped head syndrome due to INEM, who had cervical myelopathy. The first operation (anterior and posterior fusion of three vertebral bodies) failed and thus, a second operation (posterior long fusion) was necessary for the treatment of INEM.
Cauda equina syndrome (CES) is a rare complication of long-standing ankylosing spondylitis (AS). Cerebrospinal fluid (CSF) circulation disorder occurs because of chronic inflammation, and it affects the cauda equina nerve root. Based on this mechanism, there are some reports of lumboperitoneal (LP) shunt performed for preventing the development of CES symptoms by improving the CSF flow circulation. We report two cases of CES in AS treated with an LP shunt.
A 71-year-old woman developed pain in the lumbar area and lower extremities, followed by bilateral lower extremity dysesthesia and urinary disturbance. Magnetic resonance imaging (MRI) and computed tomography myelography (CTM) revealed arachnoid cysts in the dura mater and dural ectasia. CTM also revealed communication between the cyst and the subarachnoid space. We performed an LP shunt with the aim of decompression by the cyst. After the operation, the patient's pain subsided.
A 54-year-old man developed left lower extremity dysesthesia, followed by bowel and urinary disturbance. MRI revealed dural ectasia, but no obvious mass lesion was observed in the dura mater. We performed lumbar CSF drainage to evaluate whether an LP shunt would be effective. After CSF drainage, the patient's symptoms slightly improved; therefore, we performed an LP shunt. After the operation, the patient's symptoms improved slightly.
The mechanism underlying the effectiveness of LP shunt is unknown. It may normalize CSF flow circulation, leading to normalized CSF pressure in the dura mater, and decrease nerve root compression. LP shunt for CES in AS is beneficial in halting the progression of symptoms.
A spinal epidural arteriovenous fistula (AVF) is classified as a spinal arteriovenous malformation (AVM), and is much rarer than other types of AVMs. Spinal epidural AVF often presents with compressive myelopathy or radiculopathy due to the compression of the spinal cord outside the dura mater or root sleeves by an enlarged venous plexus. It is also accompanied by venous congestive myelopathy due to intradural venous reflux. The treatment of a spinal epidural AVF is occlusion of the shunt points or exclusion of an enlarged venous plexus if it compresses the spinal cord or root nerve. We report a rare case of spinal epidural hematoma caused by a spinal epidural AVF.
A 62-year-old man developed sudden neck pain, followed by quadriplegia and urinary disturbance over several hours ; the patient was transported to the hospital on that day. Cervical computed tomography showed that the ventral epidural hematoma extending between the C1 and C6 levels resulted in compression of the spinal sac. The patient did not have a traffic accident, or abnormalities in coagulation. Magnetic resonance T2-weighted images showed a T2-flow void along the C2 root sleeve ; therefore, we diagnosed the patient as a spinal epidural AVF with some dilated venous plexus by angiography. The main cause of the neurological deterioration was the compression of the spinal sac by the epidural hematoma, and there were no findings that the venous plexus compressed the root nerve. We performed endovascular embolization of the right vertebral artery and ascending pharyngeal artery using coils to reduce the flow of the spinal epidural AVF, and thereafter, C2-C6 decompressive laminectomy was performed. The patient's symptoms improved after the treatment. Spinal epidural hematoma caused by a spinal epidural AVF is rare, with only two cases reported to date of spinal epidural AVFs with a dilated venous plexus without intradural venous reflux. We report a case of a spinal epidural AVF with spinal epidural hematoma that was treated with neuro-intervention and microsurgery, with a good clinical course.
A 63-year-old woman presented with a rare case of both intraspinal and orbital inflammatory pseudotumors (IPT). The former IPT manifested as progressive dysesthesia and pain in her left leg. MRI revealed a mass at L5/S1 with extradural and intradural components, showing low signal on T1 and T2-weighted images and strong homogeneous enhancement on gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA). Intraoperatively, an extradural granulomatous lesion that was slightly adhesive to the dura mater was found and removed. Histological examination of the resected lesions revealed the presence of excessive collagen fibers infiltrated with polyclonal lymphocytes, plasma cells macrophages, and giant cells. Only a small number of IgG4-positive cells were observed. Immunostaining for the epithelial membrane antigen was negative. No malignant cells were detected. The diagnosis was consistent with IPT. Two months after surgery, orbital IPT developed. She was treated with steroids. After one year, no aggravation was observed.
IPTs usually occur in the lung and the orbit, but rarely in the spine. Although spinal IPTs are typically solitary lesions, we present a case of a patient with multiple IPTs and review the literature.